Improving Blood Management

By improving guidelines, an academic medical center research team reduced blood wastage and saved millions of dollars.

BLOOD BANKING

A multidisciplinary team at Vanderbilt University Medical Center (VUMC) in Nashville, Tenn., has developed evidence-based blood utilization practice guidelines that saved $2 million and reduced blood use by 30% at the academic medical center.1

The blood management program, which aimed to improve the processes of ordering, transporting, and storing blood, was presented at the 2016 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Conference in San Diego, Calif.

Restrictive Transfusion

“We recognized that there were good evidence-based guidelines that had been out for a number of years that could inform our decision-making to transfuse,” lead study author Barbara J. Martin, MBA, RN, told ADVANCE.

Most hospitals order a transfusion based on habit rather than an evaluated need, Martin said. Typically, the standard process is to order two units of blood—which is not always necessary. “I’ve worked in healthcare for 30 years, and that’s just what we always did,” Martin explained.

“Like many practices, it seemed to make sense that if you had a patient who was anemic, who required a transfusion—if they were anemic enough to be symptomatic—then surely they would need two units based on how much we knew that would increase the patient’s oxygen-carrying capacity,” said Martin.

“As it turned out, that wasn’t true—but we didn’t really have evidence to know that wasn’t true until studies were published in 1999,” she added. “Those studies suggested restrictive transfusion was at least as safe as a more liberal strategy—and possibly safer.”

According to study authors, reducing the amount of blood transfusions can reduce the risk of complications such as transfusion reaction, infection, volume overload, increased length of stay, and mortality.1

Improved Ordering Process

In an effort to improve blood utilization, the research team enhanced its computerized order entry, thereby basing blood-ordering practices on a precise assessment of each case. The team ordered a single unit, and if needed, followed it with a request for an additional unit. This resulted in a decrease of over 30% in red blood cell transfusions—from 675 units per 1,000 discharges in 2011 to 432 units per 1,000 discharges in 2015.1

For general and vascular surgery patients who underwent NSQIP targeted procedures – such as colectomy, proctectomy, ventral hernia, and appendectomy—between 5% and 6% were transfused with an average of 2.4 units of blood per patient in 2015, as opposed to 11% transfused with an average of 4.6 units of blood per patient in 2011.1

To make the order, transport, and storage of blood more efficient, the team created guidelines for perioperative handling.

“With regard to surgical populations, one of the questions we had with our NSQIP data, where we track the number of units patients receive in the perioperative time period, was whether we would see similar decreases in blood utilization in the NSQIP population,” Martin said. “We found that in that particular population, many of whom are transfused for acute blood loss, we still saw a significant decrease in the number of units transfused into the patient.”1

Less Waste

The research team also sought to identify ways to reduce blood wastage. To make the order, transport, and storage of blood more efficient, the team created guidelines for perioperative handling. According to the guidelines, when more than one unit of blood is ordered, it is transported in a cooler rather than the pneumatic tube. Coolers were redesigned to enhance temperature management, and a specific member of the staff is appointed control over the blood products, which includes returning unused products to the blood bank. Individual unit wastage is also reported to clinical leaders for review, and aggregate data are reported each month.1

Due to the blood utilization improvements, less than 80 units of blood were wasted in 2015, compared to 300 in 2011.1

Potential for Expansion

According to Martin, the blood management guidelines created at VUMC could certainly be used throughout other medical centers. “This is something that even the Centers for Medicare & Medicaid Services are interested in,” she said. “The Joint Commission sent out draft transfusion metrics a couple years ago that are moving towards this exact sort of blood utilization efficiency and efficacy that I think is going to push institutions to do this, whether they want to or not – and of course everybody wants to, because it’s the best thing for our patients.”

“We were able to change the mindset of the entire institution, initially, and then determine that the improved usage with decreased wastage was beneficial to patient outcomes. It is a huge success for the team, the institution, and most importantly, the patients,” said study coauthor Oscar Guillamondegui, MD, FACS, associate professor of surgery and Vanderbilt’s NSQIP Surgeon Champion in the press release.1

The significance of reducing blood wastage and utilization extends beyond the benefits for an individual medical center. “All blood is an altruistic donation,” Martin said. “It’s a limited resource and we rely on the generosity and the humanity of people to donate this product.” Blood also has a short shelf-life. If it isn’t transfused, it has to be discarded—and at some point, there may be a time when there is not an adequate blood supply, such as in mass disasters. “It’s simply a limited resource that has to be allocated efficiently and effectively,” Martin concluded.

A Team Effort

Interestingly, the research team did not encounter any difficulty in implementing these guidelines, due to strong support from the medical staff, Martin said. “As in any institution, we have key players who, when they support and endorse a process change, it goes over very well with the rest of the faculty and staff,” she explained.

Furthermore, as an academic medical center, VUMC has house staff, residents, and interns who conduct the majority of the ordering, and this initiative supported what they learn in their training. “They learn evidence-based guidelines in their training, so it made perfect sense to them—and once our faculty was good with it, it really was not difficult,” Martin said.

According to Martin, the success of this project relied on the collaboration of a multidisciplinary team. “This was not a project where quality said, ‘let’s do this,’ or the blood bank said, let’s do this,’ or transfusion medicine said, ‘this is what we’re going to do,’” Martin explained. “This was a project where we had nursing staff, anesthesiologists, attending physicians, nurse practitioners, quality folks, and data analysts all coming together in a room and saying ‘this is the best thing that can happen for our patients, and this is how we can make that happen.’”